Inspection on 04/10/07 for Martins House

This inspection was carried out on 4th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Martins House 24/10/08

Martins House 28/02/07

Martins House 06/09/06

Martins House 24/11/05

Martins House 01/08/05

Martins House 02/11/04

Martins House 10/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Martins House Jessop Road Stevenage Hertfordshire SG1 5LL Lead Inspector Claire Farrier Unannounced Inspection 4th October 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Martins House Address Jessop Road Stevenage Hertfordshire SG1 5LL Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01438 351056 01438 741528 maryjwoods@hotmail.co.uk Chauncy Housing Association Limited Miss Mary Jane Woods Care Home 63 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (63) of places Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2007 Brief Description of the Service: Martins House is owned and operated by Chauncy Housing Association, and is registered to provide personal care and accommodation for 63 older people, of whom eleven who may also suffer from dementia. There is a unit housing eleven frailer residents on the first floor. Chauncy Housing Association is a voluntary organisation. It is a charity that is run by a voluntary management committee. Martins House is the only residential establishment that the Association manages. Martins House is a purpose built three storey building situated in a residential area of Stevenage. There is a parade of shops nearby and the town centre is about a mile away. Accommodation is provided in single rooms, although there are facilities to offer shared accommodation if requested. All rooms have an ensuite toilet and washing facilities and there are a number of assisted bathrooms throughout the home. The floors are linked by two passenger lifts and the home is accessible for wheelchair use. There is a well kept garden with seating areas and raised flowerbeds that are accessible for people in wheelchairs. The Statement of Purpose and Service Users Guide provide information about the home for referring social workers and prospective clients. The current CSCI inspection report is available within the home. The current charges range from £338 to £495 per week. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spent one day at Martins House, and the people who live there and work there did not know that we were coming. The focus of the inspection was to assess all the key standards. Some additional standards were also assessed. An Expert by Experience (EBE) took part in the inspection. The EBE is a person who has experience of care services for older people. The EBE met and talked to eight people who live in the home. We also talked to some of the staff. The manager was away at the time of the inspection. The manager sent some information (the Annual Quality Assurance Assessment, or AQAA) about the home to CSCI before the inspection, and her assessment of what the service does in each area. Evidence from the AQAA has been included in this report. What the service does well: What has improved since the last inspection? The acting manager was appointed as manager of the home, and has been registered as manager with the Commission. The training officer has completed the training and development programme, and staff the programme of training for all staff has started. The dementia unit has been refurbished and redecorated since the last inspection, and provides a relaxing and sociable environment for the people who live there. The staff had a very good relationship with the people in the dementia unit, and showed a good understanding of each person’s needs and how to communicate with them. The care plans have improved. They are written in a clear language, and in a Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 6 person centred style that reflects the views of each person. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient information on residents’ care needs and access to appropriate services to enable their needs to be met. EVIDENCE: A sample of care records of the residents were inspected and there was evidence of a pre-admission assessment of needs being carried out in each case, including Social Services assessments for those who are funded by the Social Services. The home’s assessment includes specific needs for each individual, such as cultural needs and individual interests and preferences. Staff members were observed to have a good relationship with the residents. They have the skills and experience to meet most of the residents’ personal care needs. The facilities for people with dementia have improved. Kingfisher unit, for people with dementia, has been redecorated and refurbished. The Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 9 care plans provide good information on each person’s individual behaviours and how to assist them. We spent two hours sitting with people in Butterfly unit. The aim of this was to get an impression of what life is like for the people who live there. We observed that the staff have a good understanding of each person’s needs and how to communicate with them. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People in the home may be at risk because the information in the care plans is not recorded appropriately. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated that the home has improved development of the care plans. They will continue to develop the key worker system and person centred care. We looked at three care plans. They are written in a clear language, and in a person centred style that reflects the views of each person. They have good details of each persons personal care needs and how to meet them. However for some specific health care needs, there is not sufficient information to enable the staff to provide a good quality of care. One person’s care plan mentions ‘aggressive’ behaviours, but there is no management programme with a procedure for understanding and managing the behaviour. Two care plans mentioned the risk or possibility of pressure sores, but there was no clear procedure for managing and recording pressure area care. The district nurse dresses and Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 11 treats the pressure sores, but the nursing notes were not in the home. The use of body charts has started, to show where any skin sores or marks are noticed. One person had a chart showing a small sore, and the daily record stated that the person had a small sore on her bottom. But there was no record of a referral to the district nurse, or of any further observation or treatment that should be carried out. One person was admitted to hospital with pressure sores. These were long standing, and the district nurse was treating them. However investigation by social services showed that there was insufficient information and recording in the care plan. There were no risk assessments in place for a person who was at risk of falls and of pressure sores. The same person had a risk assessment for the use of bed rails on the bed. However it stated that s the person may try to climb over the bed rails. The daily records stated that on several occasions the person was very unhappy about the use of bedrails, and on one occasion she fell out of bed. The person is not safeguarded affectively from the risks of falling out of bed, with possible injury. During this inspection we spent two hours sitting with people in the area of the home where the most vulnerable people are looked after. The aim of this was to get an impression of what life is like for the people who live there. The staff spoke to people in the lounge each time they came in, and explained to each person what they were doing. The staff had a very good relationship with the people that we observed, and showed a good understanding of each person’s needs and how to communicate with them. The Expert by Experience (EBE) spoke to eight of the people who live in the home. He reported, “Generally residents were appreciative of the way staff dealt with them and their needs/preferences. Staff knocked on doors before entering.” One person said, “I really like it here. The girls are marvelous. They do what they can.” This person was most appreciative of the staff reaction to their irritable bowel condition. Another person said, “The staff are very nice and friendly. Most things are done that I want done“. A visiting relative said, “The staff are fantastic, sweet and helpful.” One person said that one member of staff was rude, and this was being addressed through the complaints procedure (see Complaints and Protection). The staff were observed to have a good relationship with the residents and to treat them with a friendly respect. They have time to talk to them and to provide the care they need without rushing. The home has sound systems in place for the safe management of medication. All medications are audited regularly. However a spot check of medication showed an error in counting that was not found during the audit. The first aid box in Butterfly unit had some essential items missing. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are supported to live full and active lifestyles. EVIDENCE: The Expert by Experience (EBE) reported, “ The residents thought that there was a good choice of activities displayed on the notice board, which they enjoyed. There is a choice of formal activities most days from Monday to Friday. The art classes (twice a week), bingo and reminiscences were particularly popular. Two people mentioned the lack of sedentary exercises. The home has agreed to pursue this.” The EBE joined some of the residents for lunch. He reported, “For the main meal at 12.30pm there was a choice the day before and a weekly menu displayed at the entrance to the large and pleasant dining room with tables for four. Today it was fisherman’s pie or roast pork with potatoes and a choice of vegetables. It was nicely presented, and overall the food was well received. The main complaint was that often the food was not hot enough. The problem according to the staff was that there was too long a time lag from kitchen to Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 13 the residents. They said that the food was ready to serve at 12.30, but the helpers didn’t start until 12.40. There were only two staff today and four yesterday to serve 32 people. One of the residents gave me a piece of their potato to taste and I found that it was lukewarm. To me the issue is one of managing this more effectively to get hot meals to the residents.” “The residents seemed to be treated with respect and a balance between help and self sufficiency but as already outlined is the question of staff numbers during this busy period. Residents said that fruit was not generally available apart from inclusion in the formal meals.” Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are confident that their concerns are listened to, and that they are safeguarded from the risks of abuse. EVIDENCE: The home has a satisfactory complaints procedure in place. The Expert by Experience (EBE) reported that there is a committee of six residents that meets about six. The residents committee was well regarded as a valued communication system; a resident member said that they meet “more regular now” and that they discuss “ small things..but important”. Two people said, “Complaints are taken seriously and invariably righted.” The Annual Quality Assurance Assessment (AQAA) stated that nine complaints were received in the last 12 months, of which four were upheld. One person told the EBE, “Some carers can be rude, with no respect. One carer told me to shut up.” This person had made a formal complaint, and said that the manager was “horrified” about it and was taking it very seriously. The home has comprehensive procedures for prevention of abuse. Training in safeguarding vulnerable adults has been provided for all the staff, and the staff spoken to were aware of their responsibilities for whistle blowing. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a safe and comfortable environment for the residents. EVIDENCE: Martins House is a purpose built three storey building. The decorations and furnishings in the home are domestic in style, and provide a homely and comfortable environment. The communal rooms include a large dining room, an activity room and three lounges. There is a well kept garden with seating areas and raised flowerbeds that are accessible for people in wheelchairs. The dementia unit has been refurbished and redecorated since the last inspection, and provides a relaxing and sociable environment for the people who live there. Appropriate signs are in place to aid people to find their way around. The units have been given new names: Primrose on the ground floor, Butterfly Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 16 on the first floor and Ladybird on the second floor. The dementia care unit is named Kingfisher. The home appeared to be clean, and appropriate procedures are in place for the control of hygiene and for effective management of laundry. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A training and development programme is in place, but not all staff have yet completed the mandatory health and safety training. EVIDENCE: All the members of staff spoken to during the inspection were enthusiastic about their work in the home, and several said that they like the residents, and that they feel well supported. The home has a good level of staffing, with twelve care assistants during the day on weekdays and seven at weekends. There are three waking night staff and one sleeping in. The training officer has completed the training and development programme, and the programme of training for all staff has started. The training that is in progress includes all the mandatory health and safety training and an induction training programme that meets the standards set by Skills for Care. Not all staff have yet completed the mandatory training. Training is also needed to meet the specific needs of the people in the home, and in particular for dementia care. Training is available for NVQ qualifications, and this needs to continue to ensure that the target of 50 qualified staff is achieved. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 18 The home has robust policies and procedures for recruitment. Two staff files were inspected for recently recruited members of staff. They both contained all the required information, including good references and a satisfactory CRB (Criminal Record Bureau) disclosure. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The views of the residents and other involved people are actively sought in order to ensure that a good quality of care is provided. EVIDENCE: Chauncy Housing Association is a charity that is run by a voluntary management committee. Martins House is the only residential establishment that the Association manages. The acting manager was appointed as manager of the home, and has been registered as manager with the Commission. She has worked in a senior position in social care since 1988, and she was appointed to the deputy manager’s position in Martins House in September Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 20 2002. She has completed the NVQ Level 4 registered managers award, NVQ level 3 award in assessing candidates who are undertaking NVQ training and a management skills development programme. The Annual Quality Assurance Assessment (AQAA) stated that the home has a management committee and management system that is proactive in addressing weaknesses. Plans for further improvement include reviewing the management structure, and specifically looking at a deputy manager post. The management committee support will be formalised with the appointment of a part time executive chairman. A staff mentoring scheme will be introduced from members of the management committee. The manager has set up a system for assessing the quality of care in the home. Surveys have been sent to residents, relatives and professionals who visit the home. The Friends of Martins House have offered to act as advocates, to help residents to complete the questionnaires in confidence. An action plan will be drawn up following the outcome of the surveys. Regular residents meetings take place, and a trustee of the management committee attends the meetings. The proprietor carries out regular monitoring visits of the home, which include discussion with residents and staff. The arrangements for management of residents’ money were inspected during the last inspection and appeared to be accurate. Money is stored safely and adequate records are maintained in order to protect service users from financial abuse. The home maintains appropriate records for the health and safety of the residents and staff in the home, and staff follow the home’s policies and procedures. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Timescale for action 29/02/08 2. OP7 13(4)(c) 3. OP8 12(1)(a) 4. OP9 13(2) The manager must ensure that all care plans provide adequate and appropriate details of each person’s needs, so that the staff have the information that they need to be able to meet their needs. Previous timescale of 31/08/07 partially met. A new timescale has been set. Appropriate and adequate risk 29/02/08 assessments must be put in place for all residents for situations in which there is any risk of harm or injury to themselves or others. The registered person must liaise 29/02/08 with the district nurses to ensure that appropriate care plans and recording are in place for all the residents’ health care needs, and in particular for the management of pressure area care. Measures must be put in place to 29/02/08 ensure that medication is audited effectively, and that any errors in medication are noted and rectified without delay. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 23 5. OP30 18(1)(c) (i) The manager must ensure that mandatory health and safety training is provided for every member of staff. All staff must also have appropriate specialised training in meeting the needs of people with dementia. Previous timescale of 31/08/07 partially met. A new timescale has been set. 31/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The arrangements for serving food at lunchtime should be adequate to ensure that food is served promptly when it is ready. Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Martins House DS0000019460.V352455.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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